An out-of-control client is verbally abusive and physically aggressive with staff members who are at increased risk for injury. Which intervention is most appropriate?
Take a time-out.
Administer oral medication.
Call a family member or friend.
Apply restraints.
The Correct Answer is D
A. Take a time-out: A time-out is generally used for de-escalating situations in less severe cases and may not be effective if the client is already physically aggressive and a risk to staff.
B. Administer oral medication: Administering oral medication can help to calm the client, but it may not be immediately effective if the client is already aggressive and out of control.
C. Call a family member or friend: Calling a family member or friend may provide emotional support, but it is not a direct intervention to address immediate physical aggression.
D. Apply restraints: When a client is physically aggressive and poses a risk of injury to themselves or others, applying restraints may be necessary to ensure safety. This should be done following proper protocols and as a last resort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased body temperature: Alcohol consumption typically causes vasodilation, which can lead to a decrease in body temperature, not an increase.
B. Cardiac dysrhythmias: Large amounts of alcohol can affect the heart's electrical system, leading to cardiac dysrhythmias.
C. Hypotension: Alcohol is a vasodilator, which can lead to a drop in blood pressure (hypotension).
D. Bradycardia: Alcohol typically causes tachycardia (increased heart rate), not bradycardia (decreased heart rate).
Correct Answer is D
Explanation
A. Sexual abuse: While sexual abuse can cause physical and emotional symptoms, the combination of unexplained injuries and fussiness/irritability is more suggestive of physical trauma.
B. Neglect: Neglect involves failure to provide for the child's basic needs, which can lead to developmental issues, but is less likely to cause unexplained injuries.
C. Munchausen syndrome by proxy: Munchausen syndrome by proxy involves a caregiver fabricating or inducing illness in a child for attention. It can cause unexplained injuries, but the focus is more on medical symptoms.
D. Shaken baby syndrome: Shaken baby syndrome results from violently shaking an infant, leading to physical injuries, irritability, and fussiness. It fits the description of unexplained injuries and behavioral changes.
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